Treating the Whole Person: Vince's Story

After a retired florist’s rent surged, he found help through his primary care provider

Published December 19, 2023

When the rent surged at Vince Consoli’s longtime Pennsylvania apartment, he was able to find help in an unlikely place: his primary care provider.

Consoli’s primary care practice, Green and Seidner Family Practice in Lansdale, Pa., about 30 miles north of Philadelphia, maintains a full-time social worker to assist patients with non-medical needs and deliver whole-person care.

“Addressing non-medical needs are just as important to a person’s health,” said Candace Scheiblein, the on-site social worker who helped Consoli apply for subsidized and income-based senior housing apartments, as well as other benefits to help him stretch the retired florist’s fixed income and maintain his wellbeing.

“When you have pressing issues, your health gets neglected. Someone who is evicted from their home, they’re not thinking about their diabetes medication or making their specialist appointment,” she said. 

Scheiblein’s practice is part of a Center for Medicare & Medicaid Innovation program, known as the Primary Care First Model, which enables primary care doctors to offer a broader range of health care and social services to meet the unique needs of their patients, improve the quality of care and reduce avoidable hospitalizations. Providers that participate in the model, like Scheiblein’s practice, may receive additional revenue from Medicare based on the practice’s performance in providing high-quality care and its ability to reduce total cost of care. It is an example of value-based care which is care focused on performance, quality and the patient's experience of care. 

Scheiblein receives referrals from doctors whose patients might be struggling to pay for rent or food, are unable to arrange transportation to their appointments, or have other social needs impacting their wellbeing, and she works to connect them with necessary resources, allowing the medical staff to focus on patients’ physical health. 

“If you are not able to access what you need to maintain your health, you can expect to be spending more time in the hospital,” she said. “It works together. People who are healthy generally have healthy social experiences too.”

She recalled one patient who had been released from an inpatient program for an eating disorder. When the woman was discharged, she was given a nutritional plan to follow, but she wasn’t able to pay for groceries. Scheiblein helped her apply for Supplemental Nutrition Assistance Program (SNAP) benefits so she could have enough food at home.

Scheiblein said having a social worker embedded in a primary care practice is uncommon but should be expanded.

Research has shown that social workers can be an important addition to primary care and can improve health outcomes, but most primary care providers don’t have the time or resources to connect patients with non-medical services. On any given day, Scheiblein might go to a housing hearing, be on the phone with a food pantry or meeting with patients in the office or over the phone, allowing the primary care doctors to focus on patients’ medical needs.  

She said many people are reluctant to ask for help, but they often trust their primary care provider, which gives her an edge in working with new patients.

“So many patients that already trust their primary care providers and I have one foot in the door,” she said. “You have access to people. They are coming here with a problem.”

Consoli said when he reached out for help elsewhere, he said he felt cast aside, but with Scheiblein, he’s found an advocate. 

“You feel comfortable with her, she’s not rude or nasty,” he said. “She’s helped me with a lot of issues confronting me today, financially, emotional and physically.”